Welcome Sheet



We currently use an automated system to send you text messages, emails and voice recordings for appointment reminders and notifications about glasses and contact lenses. Check this box if you prefer to not to use this system: Don't Use

Are we using vision insurance for your visit?

If you checked YES, who is the responsible party for billing any insurance copays, overages or non-covered services?

If you checked SPOUSE or PARENT, please provide their contact information:

Do you have allergies (environmental, drug, etc.)?

Do you use tobacco products?

Do you drink alcohol?

Do you use illegal drugs?

Note any family history [parents, grandparents, siblings, children (living or deceased)] and indicate maternal or paternal.

Blindness

Cataract

Crossed Eyes

Diabetes

Detached Retina

Glaucoma

Heart Disease

High Blood Pressure

Macular Degeneration

Do you currently have, or have you ever had, any problems in the following areas? Please check all that apply:

Eyes













Bones, Joints, Muscles



Neurological



Psychiatric



Ears, Nose, Mouth, Throat




Respiratory


Lymphatic/Hematologic

I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me to obtain payment of my insurance benefits.

If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form.


Note: Please allow up to 10 seconds for the form to submit.